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How to fill out the Amerigroup PF-MULT-0023-12 online
The Amerigroup PF-MULT-0023-12 form is designed for providers to submit payment disputes and claim correspondence. This guide offers clear and supportive steps to help you fill out the form online efficiently.
Follow the steps to complete the form accurately.
- Press the ‘Get Form’ button to obtain the form and open it in your editor.
- Enter the member's first and last name in the designated fields.
- Fill in the member's date of birth accurately.
- Choose the appropriate Amerigroup, Medicaid, or Medicare ID number and circle the corresponding option.
- Input your first and last name as the provider, followed by your National Provider Identification (NPI) number.
- Indicate whether you are a participating or nonparticipating provider by checking the appropriate box.
- If applicable, attach the completed Centers for Medicare & Medicaid Services (CMS) Waiver of Liability form for a Medicare member.
- Provide your contact name and phone number as the provider's contact information.
- Complete your street address, city, state, and ZIP code.
- Fill in your claim number, billed amount, and amount received.
- Record the start and end dates of service and add the authorization number.
- Choose the reason for the payment dispute from the provided options and describe it in detail.
- If necessary, attach additional sheets for further explanation, including appropriate medical records.
- For claim correspondence, check the appropriate box and indicate the reasons for your request.
- Mail the completed form and any supporting documentation to the address provided.
Complete your Amerigroup PF-MULT-0023-12 form online to ensure accurate processing of your request.
An appeal refers to a formal request to review and overturn a decision, while a dispute can represent a broader disagreement that may not directly challenge a specific ruling. In the context of Amerigroup PF-MULT-0023-12, understanding these terms helps clarify the steps you need to take. If you encounter issues, using resources available on the uslegalforms platform can guide your approach effectively.
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